A completed application form and a filing fee of 100 Applicants applying to take the licensing examination may choose to submit the licensing fee at the same time as the examination fee Official ID: 93405
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BUSINESS,CONSUMERSERVICES,ANDHOUSINGAGENCY•GAVINNEWSOM,GOVERNORCEMETERYANDFUNERALBUREAU1625N.MarketBlvd.,SuiteS-208,Sacramento,CA95834P916.574.7870F916.928.7988www.cfb.ca.govAPPLICATIONFORFUNERALDIRECTOREMAMINATIONANDLICENSEFEEApplicationandExaminationFee$100LicenseFee$200LICENSENUMBERISSUEDFDRSECTIONA:APPLICANTINFORMATIONLastNameFirstMiddleInitialResidenceAddressCityStateNipCodeMailingAddress�Ifdifferentfromabove3CityStateNipCodeAddressyouwantprintedonyourlicense�Ifapplicable3CityStateNipCodeResidenceTelephoneNumber�3DaytimeTelephoneNumber�3DateofBirthSocialSecurityNumberE-mailAddress�Notrequired3FormerName�Ifapplicable3SECTIONB:EDUCATIONINFORMATIONTositfortheFuneralDirector’sexamyoumustpossessanAssociateinArtsorAssociateinScience,orhigherdegreeortheequivalentof60collegeunitsasrecognicedbytheWesternAssociationofCollegesandUniversities,oranynationallyrecognicedaccreditingbodyofcollegesanduniversities.Haveyourequested�OfficialTranscripts”besenttotheBureauCYesNoIfno,youwillnotbeissuedalicenseuntiltheBureaureceives�OfficialTranscripts”andallotherrequirementsforlicensurehavebeenmet.�OfficialTranscripts”aretranscriptssentdirectlyfromtheeducationalinstitution,inasealedenvelope,totheCemeteryandFuneralBureauat1625NorthMarketBlvd.,Ste.S-208,Sacramento,CA95834SECTIONC:EMAMINATIONINFORMATIONHaveyoupreviouslytakentheexaminationyouareapplyingforCNoYesIfyes,indicateprevioustestdate�s3PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPAreyouapplyingtotakemorethanoneexamonthesamedateCNoYesIfyes,whatotherexamhaveyouappliedtotakeCPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPFORBUREAUUSEONLYDateCashieredAmountCashieredATSNumberReceiptNumberSIDNumber/OnFileWithEnforcementCheckOfficialTranscriptsReceivedExamResultsDateLicenseIssuedRev.05/09CemeteryandFuneralBureau–wwww.cfb.ca.govPage2of3✔✔✔✔ 6" 11$1@ 11@pDGofoq/p8f/6VHOGotf/pGy8f/4qGeOIf / / $ I$". q4fgiPqliLIqLoHrmibnLroq( R qgL�ArloqoflRq8lLiibf�iqhLOAUpGhdOq4fAg�I�q;fRq $ q$ .L1 q P T L T /q�Sq/q MN N( (LLG )(O KIR KMRlicensure cttegories spplied towsrds tnd correct BUSINESS,CONSUMESERVICES,ANHOUSINGAGENCYGAVINEWSOM,GOVERNORCEMETERYANFUNERALBUREAU1625MarketBlvd.,SuiteS-208,Sacramento,CA95834916.574.7870916.928.7988w.cfb.ca.govNOTICEONCOLLECTIONOFPERSONALINFORMATIONCollectionandUseofPersonalInformationTheCemeteryandFuneralBureau�Bureau3oftheDepartmentofConsumerAffairscollectsthepersonalinformationrequestedonthisforminaccordancewithBusinessandProfessionsCode�BPC3sections30,35,114.3,114.5,115.4,115.5,144,480,CemeteryandFuneralAct�BPCsection7600et.seq.3,andtheInformationPracticesAct.TheBureauusesthisinformationprincipallytoidentifyandevaluateapplicantsforlicensure,issueandrenewlicenses,andenforcelicensingandreportingstandardssetbylaandulatin.MandatorySubmissionSubmissionoftherequestedinformationismandatoryunlessotherwisenotedontheapplicationand/orform.TheBureaucannotconsideryourapplicationforlicensureorrenewalunlessyouprovidealloftherequestedinformation.AccesstoPersonalIformationYoumayreviewtherecordsmaintainedbytheBureauthatcontainyourpersonalinformation,aspermittedbytheInformationPracticesAct.Seebelowforcontactinformation.PossibleDisclosureofPersonalInformationWemakeeveryefforttoprotectthepersonalinformationyouprovideus.Theinformationyouprovide,however,maybedisclosedinthefollowingcircumstances:InresponsetoPublicRecordsActrequest�GovernmentCodeSection6250andfollowing3,asallowedbytheInformationPracticesAct�CivilCodeSection1798andfollowing3;ToanothergovernmentagencyasrequiredbyStateorFederallaw;or,Inresponsetocourtoradministrativeorder,subpoena,orsearchwarrant.ContactInformationForquestionsaboutthisnoticeoraccesstoyourrecords,youmaycontacttheCustodianofRecords,CemeteryandFuneralBureauat1625NorthMarketBoulevard,SuiteS-208Sacramento,CA95834,byphoneat�9163574-7870,orbye-mailatmailcfb@dca.ca.govForquestionsabouttheDepartment’PrivacyPolicy,youmaycontacttheDepartmentofConsumerAffairsat1625NorthMarketBoulevard,Sacramento,CA95834,byphoneat�8003952-5210,orbye-mailatdca@dca.ca.gov